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1 LAC-USC Pulmonary Disease Consults RESIDENT AND INTERN ORIENTATION First Day of Rotation: Report for rounds at 10:00 am Orientation will be at 9:45 am Conference Room between MICU 4A/4B Faculty in Charge of Rotation: Richard Lubman, MD [email protected] (323)409-7184 Pulmonary, Critical Care and Sleep Medicine Division Keck School of Medicine of USC 2020 Zonal Avenue, IRD 720 Los Angeles, CA 90033 Phone: (323) 409-7184

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Page 1: LAC-USC Pulmonary Disease Consults...1 . LAC-USC Pulmonary Disease Consults . RESIDENT AND . INTERN . ORIENTATION . First Day of Rotation: Report for rounds at 10:00 am . Orientation

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LAC-USC Pulmonary Disease

Consults

RESIDENT AND INTERN

ORIENTATION

First Day of Rotation: Report for rounds at 10:00 am Orientation will be at 9:45 am

Conference Room between MICU 4A/4B

Faculty in Charge of Rotation:

Richard Lubman, MD [email protected]

(323)409-7184

Pulmonary, Critical Care and Sleep Medicine Division Keck School of Medicine of USC

2020 Zonal Avenue, IRD 720 Los Angeles, CA 90033 Phone: (323) 409-7184

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DAILY SCHEDULE

8:30 AM – 9:30 AM Morning Conference 10:00 AM – 12:00 PM Teaching Rounds 12:00 PM – 1:00 PM Lunch/Conference 1:00 PM – 5:00 PM Patient Care and Management 5:00 PM – 6:00 PM Signout to Night residents

WEEKLY SCHEDULE

MONDAY 8:30-9:30 AM Morning Conference IRD 734 1st TUESDAY 8:30-9:30 AM Chest Conference IRD 734 2nd TUESDAY: 8:30-9:30 AM Chest Infectious Disease Conference IRD 734 3rd TUESDAY: 8:30-9:30 AM Lung Pathology Conference Doheney Eye Building 2nd floor Pathology Conference Room 4th TUESDAY:

8:30-9:30 AM Morbidity and Mortality Conference IRD 734 WEDNESDAY 8:30-9:30 AM Morning Conference IRD 734 THURSDAY 8:30-9:30 AM Grand Rounds IRD 734 FRIDAY 8:30-9:30 AM Morning Conference IRD 734

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IMPORTANT PHONE NUMBERS/CONTACT INFO

MICU A 93984 MICU B 93986 MICU Fellow 93992 Medicine Subspecialty Consults ALLERGY: 323-226-3813 CARDIOLOGY: Cards Consult: 93982 CCU VOIP: 93981 Cath lab: 95284, 95783, 97601 Cath Recovery: 95284 Nuc Med: 97468 Stress Lab Marci: 97468 EKG tech: 97466, 96705 Echo: 97444 Tech 97445. Read: 97520, 97855 ENDOCRINE: 323-442-2807 GERIATRICS: 323-226-3638 GI/LIVER Consults: 97974 GI work room: 92679 GI Lab/Scheduling: 95530 HEME/ONC Heme consult: 323-226-6969 Onc consult: 323-226-6395 Pain 213-919-8545 or 97483 Rad Onc: 95019 appt 95023 ID: Consults: 323-226-3851 TB control: 323 226 7962 Epidemiology: 96645 Rand Schrader clinic 323-343-8255 HIV clinic (5P21) 323-343-8258

PALLIATIVE: 98532 PULM: Consults: 97184 Bronch Suite 94730 Sleep Lab 97936 RENAL: Renal consult: call VOIP for fellow A Renal fellow VOIP: A 93996, B 93997 HD charge nurse VOIP: 93243 RHEUM: 323-226-7889 Rheum immuno lab: 97141 TOX: 97028 Neurology / Psychiatry Neuro consult: 97405, 97376 Neuro resident VOIP: 94536 Neuro wards VOIP: 94537 EEG: 97388 Psychiatry: through Orchid Psych Workroom 96352 Surgical Consults ACS consults: 97728 (ACS non-trauma VOIP 97769) ACS A 94737 (213-919-8751)

ACS B 94736 (213-919-8752)

ACS C 94741 (213-919-8755)

ACS D 94752 (213-919-4529)

Burns: 97996 Cardiothoracic: 97819 NP 213-717-3593 Colorectal: 213-919-7363 ENT 213-919-7000 7G: 97309 HBS: 213-919-8749

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MIS: 213-919-8581 NSGY: 97405 OB/Gyn: 94198 Gyn-Onc: 213-919-0468 OMFS: 213-217-0215 OMFS Resident Rm 91558 Ophtho: 213-919-9254 / Inpt clinic 6C 97225 / Outpt clinic 95227 Ortho: 97227; 213-919-3487, Ortho On Call 213-208-1193 Plastics: 213-919-7299 SICU: 91817 – consults for PEG/Trachs Surg Onc: 323-226-4981 Thoracic Foregut: 323-260-0148 Tumor/Breast: 213-990-8574 Urology: 213-919-2156/Workroom: 96995 Vascular: 213-919-8750 Vasc Lab: 94618 ED: Resus 96711 North 96707 West 93750 East 97095 Resus 2* 91615 Res 91619 Int 91617 North 2* 91625 Res 91659; Int 91628, 91629 West 93750 Psych ED 97085 ED Obs 97229 SOU 97728/97729 Ancillary Authorization code for long distance calls: 2112039280 Dietician/Nutritionist: 96901 Dynamics Orthotics 213-383-921 Home O2 Eval: Amber 323-729-1462 Inpatient Translator 93600 IT: 98000

Pager operator: 94906 PICC nurse: 94186, 90779 // 94802 PT/OT: 97437 Weekends: 95096 Rancho liaison (Edith): 91333 Rancho admission: 562-401-6554 RT: 92216 Speech Therapy: 95082 SW main: 95253 SW Inpatient: 97448 SW ED: 96883 SW Substance Counseling 95363 SW weekends/nights: 213-919-7063 Transport: 97348 ICU transport: 95327 Nurse Manager 91688 Supervisor: 92965 UR Inpatient: 92962 UR ED: 95001 Labs/Pathology Blood Bank 97134 Core: 97039 Micro 97012 Cyto 91378 Cytology/FNA biopsy: 94615 Heme (get smears): 91804 Pathology 94606 Phlebotomy 97040 Pharmacy Anticoag: 97606 Anticoag Clinic: 95181 Chemo: 97551 Inpt Pharm: 97641 CCU Pharm: 93730 MICU Pharm: 93936 MICU Pharm: 91888 Discharge Pharm: 97165 TPN: 97438

Clinics/Outpatient Pharmacy Adult Primary Care East: 94051 (4p81), 94054 (4p61) Clinic Tower Pharmacy: 91893 OPD Zonal Pharmacy: 96763

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Wards 1E Jail 94568 Jail Command Ctr 213-893-5544 2E 96355 3C 93354 4AL 93929 4AH 93933 4BL 97490 4BH 94005 4C 97405 4D 97111 4M 97112, 97113 5A 97391 5F 97393 5BL 95637 5BH 98050 5C 97819 6A 97730 6B 97812 6C 97225 6D 97227 7A 92592 7B 94021 7C 97312 7D 97304 8A 97651 8B 92746 8A Res Lounge: 98652 Administrative Chief On Call: 213-375-4455 Chief’s Office: 323-409-7644; 96625, 96626, 96627 Office of educational affairs: 323-409-7556

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GOALS AND LEARNING OBJECTIVES First Day on Service: It is the Consult Fellow's responsibility to orient all in-coming house officers and medical students.

Person in Charge of Rotation: Richard Lubman, MD (323) 409-7184 [email protected] Overview: The overall goal of the Inpatient Consult Service rotation at LAC+USC Medial Center is for trainees to develop clinical competence in diagnosing and managing a broad spectrum of pulmonary diseases. Trainees are expected to evaluate patients on whom they are consulted, formulate a comprehensive differential diagnosis, order and interpret appropriate diagnostic studies in a cost-effective manner and make treatment recommendations including triage decisions regarding the requirement for transfer to a higher level of care. Trainees are expected to gain expertise to serve as consultants to other services in the diagnosis and management of patients with pulmonary disease. They must become knowledgeable in procedures and additional diagnostic studies required for optimal diagnosis and management of patients with pulmonary disease. Trainees will receive didactic education through conferences and lectures on essential topics where they will acquire the skills to critique and implement evidence-based medicine as applicable to their practice.

The Consultation Team

The consultation team is comprised of 2 medical residents, one Fellow and an Attending Physician. Medical

students may also be assigned to the team. Because of the volume of consultations generated each week, it is

essential that the team work very closely together to optimize patient care.

Medical students and residents are assigned new routine and emergency consults on a rotating basis until 4:00

p.m. The on-call resident takes all emergency consults. The medical students and residents should write out

each consultation legibly and formulate a differential diagnosis and management strategy on each patient. The

consult resident should present all new cases to the Fellow and Attending within 24 hours, and emergency

consults must be presented to the Fellow immediately after evaluation. The Fellow and resident must write

daily notes on all patients until the Attending Physician agrees to sign off the case.

All consults are logged in a consult book located in room IRD 727 or 729. It is the residents' responsibility to

periodically check the consult book for new consults. The consult service may be called to help evaluate

patients in the Emergency Room and throughout the Hospital for transfer to the MICU. The consult residents

and Fellow must work closely with the MICU services and be aware of bed availability to allow for expedient

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transfer of patients requiring intensive care monitoring. The ICU Fellow or the on-call Fellow must be

informed of all admissions to the MICU.

Teaching Sessions

The Consult Fellow is responsible for teaching house officers and medical students the fundamentals of

Pulmonary and Critical Care Medicine. Some of the topics that should be covered include ventilator

management, treatment and management of asthma, COPD, community acquired and nosocomial pneumonia,

etc.

Because of the acuity of patients being followed on the consult service, it is essential for the residents and

fellow to be punctual to all scheduled rounds. The Fellow's work rounds are an opportunity for the consult team

to discuss and evaluate the consults from the night before and the difficult management cases. All new

consultation notes require the Attending Physician's signature.

Sign out rounds are essential to ensure continuity of care for patients on the consult service. The on-call

resident and Fellow should be aware of the difficult management cases as well as those patients who are on the

list for the MICU.

Medical Chest Clinic (Wednesday afternoons) is an opportunity for medical students and house officers to

follow and manage patients with common pulmonary conditions in an outpatient setting. The Clinic is

mandatory for all residents. The on-call resident may be excused to evaluate emergency consults. Primary

medical clinic assignments take priority over chest clinic.

On-Call

Residents take call from home every fourth night. The on-call resident is responsible for all emergency consults

from 3:00 p.m. to 8:00 a.m. All consults are discussed with the on-call Fellow. The consult resident has

weekends off entirely unless on-call. Residents are required to be in the hospital until 5:00 p.m. (or later if there

are unstable patients) on weekdays.

Procedures

All procedures including bronchoscopies, chest tubes and pleural biopsies should be referred to the procedure

Fellow. It is the consult team and procedure Fellow's responsibility to perform requested procedures when

indicated in an expedient fashion.

Telephone Numbers

Microbiology 409-7012

Pathology 409-4606

Pulm/ICU Consults 409-7184 (8:00 a.m. - 4:00 p.m.) –

2345 (to find out Resident on- call that night after 3:00 p.m., or check AMION.COM)

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Bronchoscopy Room 409- 7954

Cytology 409-4615

MICU I 409-7461

MICU II 409-3929

Division Office 409-7184

Educational Methods: Direct observation of patient care and bedside teaching occur in the setting of daily inpatient rounds with the attending. Residents evaluate and treat patients both in the capacity of follow-up as well as initial evaluation. The supervising attending reviews and critiques the resident’s interpretation of diagnostic studies and formulation of assessments and plans. Residents additionally attend didactic conferences as indicated above. Recommended educational resources for this rotation include the following: Additional critical care resources:

� http://www.thoracic.org/ � http://www.chestnet.org � http://www.sccm.org � http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf � http://www.ardsnet.org/files/pbwtables_2005-02-02.pdf � http://www.survivingsepsis.org/Guidelines/Pages/default.aspx � https://www.thoracic.org/statements/cc.php

Evaluation and Feedback Methods: The attending physician is responsible for providing verbal feedback and must submit evaluations of the resident physicians in MyEvaluations. The attending must meet face-to-face to provide end-of-rotation feedback with all of the house officers they evaluate and indicate that discussion on the evaluation form. Evaluations must be completed within one week of completing a rotation. Peer evaluations for other trainees on the team should be completed in a timely manner. Reminders for Interns and Residents on the Pulmonology Service at LAC-USC 1. DO NOT take direct consults. (Only from staff office).

2. Jail Consults at CLINIC need to be seen by 2:00 p.m.

3. Routine Calls are seen within 24 hours that the consult was called in. Emergency Calls are seen within 1-hour of the consult called in. 4. On clinic day (Wednesday) you will receive routines and the on-call resident for that day will see

emergencies after 12:00 p.m. 5. You must attend rounds every morning from 10:00 am till Noon. NO EXCEPTIONS!

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LEARNING OBJECTIVES FOR TRAINEES

Patient Care: 1) Residents will diagnose, assess the severity, recommend additional diagnostic studies (including but not

limited to pulmonary function tests, inhalation challenge test and skin testing) and formulate a therapeutic plan for patients with asthma consistent with current asthma management guidelines

2) Residents will diagnose, assess the severity, recommend additional diagnostic studies (including but not limited to pulmonary function testing) and formulate a therapeutic plan for patients with chronic bronchitis, emphysema and bronchiectasis

3) Residents will diagnose, assess the severity, recommend additional diagnostic studies (including but not limited to pulmonary function testing) and formulate a therapeutic plan for patients with developmental disorders of the respiratory system including cystic fibrosis

4) Residents will evaluate, recommend additional studies (e.g., CT scans, bronchoscopy) and make therapeutic recommendations for patients with primary and metastatic pulmonary malignancy

5) Residents will diagnose, recommend additional diagnostic studies (e.g., sputum examination, bronchoscopy with bronchoalveolar lavage) and formulate treatment recommendations for pulmonary infections in immunocompetent and immunosuppressed patients including tuberculosis, fungal nosocomial and HIV-related infections

6) Residents will diagnose, assess the severity, recommend additional diagnostic studies (including but not limited to pulmonary function testing, HRCT and biopsy) for patients with diffuse interstitial lung disease, including management of end-stage lung disease and referral for transplant evaluation

7) Residents will evaluate, recommend additional diagnostic studies and formulate a treatment plan for patients with pulmonary thromboembolism

8) Residents will evaluate, recommend additional diagnostic studies and formulate a treatment plan for patients with occupational and environmental lung diseases

9) Residents will evaluate, recommend additional diagnostic studies and formulate a treatment plan for patients with iatrogenic diseases including drug-induced lung disease, radiation pneumonitis and oxygen-induced

10) Residents will evaluate, recommend additional diagnostic studies (e.g. thoracentesis and pleural biopsy) and formulate a treatment plan for patients with disorders of the pleura and mediastinum

11) Residents will evaluate, recommend additional diagnostic studies and formulate a treatment plan for patients with systemic pulmonary diseases including collagen vascular disease and granulomatous diseases (e.g. sarcoidosis)

12) Residents will diagnose, assess the severity, recommend additional diagnostic studies and formulate a treatment plan for patients with pulmonary vascular disease

13) Residents will effectively diagnose and recommend management for patients with decompensated liver disease and its complications (GI bleeding, encephalopathy and coagulopathy), renal failure, cardiovascular disease, fluid and electrolyte abnormalities, endocrine, hematologic and nervous system disorders and identify prognostic factors influencing progression of these disorders

14) Residents will assess nutritional needs of patients with chronic pulmonary disorders (including cystic fibrosis) and recommend appropriate nutritional supplementation in a multidisciplinary fashion

15) Residents will recognize, evaluate and recommend management for anaphylaxis and allergic reactions 16) Residents will evaluate, recommend additional diagnostic studies and formulate a treatment plan for

critically ill patients in non-medical ICU settings (burn patients, trauma patients, neurological and surgical patients)

16) Residents will address psychosocial and end-of-life issues in patients with chronic lung disease and with their families, including the principles of advanced directives and terminal care

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17) Residents will participate in multidisciplinary discharge planning of patients with pulmonary diseases including assessment of needs for supplemental oxygen and other respiratory care

Medical Knowledge: 1) Residents are expected to develop the skills to obtain a history, perform a complete physical examination, and interpret laboratory, radiologic and other studies to diagnose and manage patients with a broad spectrum of acute and chronic pulmonary diseases and systemic disorders that involve the pulmonary system 2) Residents are expected to acquire knowledge in the following specific areas in order to be able to evaluate and formulate a therapeutic plan for patients with acute and chronic pulmonary disorders: - pathophysiology and management of obstructive lung diseases including asthma, chronic bronchitis,

emphysema and cystic fibrosis/bronchiectasis - diagnosis and management of pulmonary malignancy - management of pulmonary and nosocomial infections including HIV-related infections - pathophysiology, diagnosis and management of interstitial lung diseases - diagnosis and management of occupational and environmental lung diseases - diagnosis and management of iatrogenic diseases including drug-induced lung disease, radiation

pneumonitis and oxygen-induced - diagnosis and management of pulmonary thromboembolism - criteria for referral for lung transplantation - guidelines for assessment of operative risk in patients with chronic pulmonary disease - diagnosis and management of disorders of the pleura and mediastinum - diagnosis and management of patients with systemic pulmonary diseases including collagen vascular

disease and granulomatous diseases (e.g. sarcoidosis) - diagnosis and management of patients with pulmonary vascular disease - post-operative complications - nutritional evaluation and recommendations in patients with pulmonary disease - indications and complications of tracheostomy - chronic weaning - indications for pulmonary rehabilitation - guidelines for referral for sleep evaluation - guidelines for use of supplemental oxygen - psychosocial and end-of-life issues 3) Residents are expected to learn indications and contraindications, and demonstrate competency in the following diagnostic studies: - interpretation of pulmonary function studies including inhalation challenge tests, exercise studies and 6 minute walk test - interpretation of chest CT scans - interpretation of pulmonary angiograms - interpretation of arterial blood gases, electrolyte and acid-base abnormalities - interpretation of lung biopsy samples for infectious agents, cytology and histopathology 4) Residents are expected to learn the indications and contraindications for the following diagnostic studies: - flexible fiberoptic bronchoscopy with bronchoalveolar lavage, endobronchial and transbronchial lung

biopsy

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- needle or chest tube insertion for management of pneumothorax - arterial cannulation for arterial blood gas analysis

PULMONOLOGY CONSULT MILESTONES PER TRAINING YEAR PGY2/3/4 Patient Care Gathers and synthesizes essential and accurate information to define each patient’s clinical problem(s).

• Obtains relevant historical subtleties, including sensitive information that informs the differential diagnosis

• Identifies subtle or unusual physical exam findings • Efficiently utilizes all sources of secondary data to inform differential diagnosis • Effectively uses history and physical examination skills to minimize the need for further diagnostic

testing Develops and achieves comprehensive management plan for each patient

• Appropriately modifies care plans based on patient’s clinical course, additional data, patient preferences, and cost-effectiveness principles

• Recognizes disease presentations that deviate from common patterns and require complex decision-making, incorporating diagnostic uncertainty

• Manages complex acute and chronic conditions Manages patient with progressive responsibility and independence

• Independently manages patients across applicable inpatient, outpatient, and ambulatory clinical settings who have a broad spectrum of clinical disorders, including undifferentiated syndromes

• Seeks additional guidance and/or consultation as appropriate • Appropriately manages situations requiring urgent or emergency care • Effectively supervises the management decisions of the team in all appropriate clinical settings

Requests and provides consultative care • Provides consultation services for patients with basic and complex clinical problems requiring detailed

risk assessment • Appropriately integrates recommendations from other consultants in order to effectively manage patient

care Medical Knowledge Possesses clinical knowledge.

• Possesses the scientific, socioeconomic, and behavioral knowledge required to provide care for complex medical conditions and comprehensive preventive care

Knowledge of diagnostic testing and procedures • Interprets complex diagnostic tests accurately while accounting for limitations and biases • Knows the indications for, and limitations of, diagnostic testing and procedures • Understands the concepts of pre-test probability and test performance characteristics • Teaches the rationale and risks associated with common procedures and anticipates potential

complications of procedures Scholarship

• Critiques specialized scientific literature effectively

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• Dissects a problem into its many component parts and identifies strategies for solving • Uses analytical methods of the field effectively

Systems-Based Practice Works effectively within an interprofessional team (e.g., with peers, consultants, nursing, ancillary professionals, and other support personnel)

• Understands the roles and responsibilities of, and effectively partners with, all members of the team • Efficiently coordinates activities of other team members to optimize care

Recognizes system error and advocates for system improvement. • Identifies systemic causes of medical error and navigates them to provide safe patient care • Advocates for safe patient care and optimal patient care systems • Activates formal system resources to investigate and mitigate real or potential medical error • Reflects upon and learns from own critical incidents that may lead to medical error

Identifies forces that impact the cost of health care, and advocates for and practices cost-effective care • Consistently works to address patient-specific barriers to cost-effective care • Advocates for cost-conscious utilization of resources such as emergency department visits and hospital

readmissions • Incorporates cost-awareness principles into standard clinical judgments and decision-making, including

use of screening tests Transitions patients effectively within and across health delivery systems

• Appropriately utilizes available resources to coordinate care and manage conflicts to ensure safe and effective patient care within and across delivery systems

• Actively communicates with past and future caregivers to ensure continuity of care • Anticipates needs of patient, caregivers, and future care providers and takes appropriate steps to address

those needs Practice-Based Learning and Improvement Monitors practice with a goal for improvement

• self-reflects upon practice or performance, and consistently acts upon those reflections to improve practice

• Recognizes sub-optimal practice or performance as an opportunity for learning and self-improvement • acts upon opportunities for learning and self-improvement

Learns and improves via performance audit • Analyzes own clinical performance data and actively works to improve performance • Actively engages in opportunities to achieve focused education and performance improvement • Demonstrates the ability to apply common principles and techniques of quality improvement to improve

care for a panel of patients Learns and improves via feedback

• Solicits feedback and incorporates feedback • Welcomes unsolicited feedback • Able to reconcile disparate or conflicting feedback

Learns and improves at the point of care • reconsiders an approach to a problem, asks for help, or seeks new information • Translate medical information needs into well-formed clinical questions independently

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• Guided by the characteristics of clinical questions, efficiently searches medical information resources, including decision support tools and guidelines

• Independently appraises clinical research reports based on accepted criteria Professionalism Has professional and respectful interactions with patients, caregivers, and members of the interprofessional team (e.g., peers, consultants, nursing, ancillary professionals, and support personnel).

• Demonstrates empathy, compassion, and respect to patients and caregivers in all situations • Anticipates, advocates for, and actively works to meet the needs of patients and caregivers • Demonstrates a responsiveness to patient needs that supersedes self-interest • Positively acknowledges input of members of the interprofessional team and incorporates that input into

plan of care, as appropriate • Regularly reflects on, assesses, and recommends physician and colleague self-care and wellness

Accepts responsibility and follows through on tasks • Prioritizes multiple competing demands in order to complete tasks and responsibilities in a timely and

effective manner • Willingly assumes professional responsibility regardless of the situation

Responds to each patient’s unique characteristics and needs • Recognizes and accounts for the personal characteristics and needs of each patient • Appropriately modifies care plan to account for a patient’s unique characteristics and needs

Exhibits integrity and ethical behavior in professional conduct • Demonstrates integrity, honesty, and accountability to patients, society, and the profession • Actively manages challenging ethical dilemmas and conflicts of interest • Identifies and responds appropriately to lapses of professional conduct among peer group • Regularly reflects on personal professional conduct • Identifies and manages conflicts of interest

Interpersonal and Communication Skills Communicates effectively with patients and caregivers

• Identifies and incorporates patient preference in shared decision-making in complex patient care conversations and the plan of care

• develops therapeutic relationships with patients and caregivers, including persons of different socioeconomic and cultural backgrounds

Communicates effectively in interprofessional teams (e.g., with peers, consultants, nursing, ancillary professionals, and other support personnel).

• actively engages in collaborative communication with appropriate members of the team • employs verbal, non-verbal, and written communication strategies that facilitate collaboration

with team members to enhance patient care Appropriate utilization and completion of health records

• Patient-specific health records are organized, timely, accurate, comprehensive, and effectively communicate clinical reasoning

• Provides effective and prompt medical information and test results/ interpretations to physicians and patients

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REFERENCE ARTICLES

ASTHMA:

Web site for latest treatment guidelines: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

Nelson HS, Weiss ST, Bleecker ER, et al, SMART Study Group. The salmeterol multicenter asthma research trial. Chest 2006; 129:15-26. This randomized, double-blinded, placebo-controlled, observational study (N= 26,355) showed a small, but statistically significant increase in respiratory-related and asthma-related deaths for the population receiving salmeterol. It is uncertain whether poor outcomes were due to physiologic treatment effects, genetic factors, lack of concomitant inhaled corticosteroid use, or patient behaviors.

Jaeschke R, O’Byrne PM, Mejza F, et al. The safety of long-acting beta-agonists among patients with asthma using inhaled corticosteroids: systematic review and metaanalysis. Am J Respir Crit Care Med. 2008; 178:1009-16. Results of the above SMART study have prompted greater scrutiny of long-acting beta-agonist use. This metaanalysis suggests these medications do not reduce or increase the risk of asthma-related admits or all-cause mortality when administered concomitantly with inhaled corticosteroids. The analysis was not able to address risk based on race or in children.

Boushey HA, Sorkness CA, King TS, et al. Daily versus as-needed corticosteroids for mild persistent asthma. N Engl J Med 2005; 352:1519-28. A year-long RCT of 225 adults with mild persistent asthma compared prn inhaled corticosteroids based upon symptom-based action plan vs. daily treatment with ICS vs. daily leukotriene inhibitor and found no difference in morning peak expiratory flow and the rate of asthma exacerbations despite the prn corticosteroid group using an average of only 0.5 week of steroid per year. The ICS group had superior asthma control scores and lower markers of airway inflammation. Some attribute this relatively modest benefit of regular ICS use to the lower exacerbation rate in this study compared to its predecessors, which speaks to the challenge of identifying mild persistent asthmatics.

Malmstrom K, Rodriguez-Gomez G, Guerra J, et al. Oral montelukast, inhaled beclomethasone, and placebo for chronic asthma. A randomized controlled trial. Ann Intern Med 1999;130:487-95. Both inhaled steroid and a leukotriene inhibitor were better than placebo. Beclomethasone was significantly better than montelukast in reducing exacerbations and symptoms.

O’Byrne PM, Bisgaard H, Godard PP, et al. Budesonide/formoterol combination therapy as both maintenance and reliever medication in asthma. Am J Respir Crit Care Med 2005: 171;129-36. This study included 2,760 asthmatics with a history of at least one exacerbation in the previous year and regular need for rescue bronchodilators despite baseline use of, on average, moderate doses of inhaled corticosteroid. Patients randomized to budesonide/formoterol (80/4.5) bid and prn had prolonged time to exacerbations requiring medical intervention compared to combination therapy with terbutaline prn or higher dose steroid (budesonide 320 bid) plus terbutaline prn. Subsequent RCTs have also shown favorable outcomes with this approach.

Bateman ED, Boushey HA, Bousquet J, et al. GOAL Investigators Group. Can guideline-defined asthma control be achieved? The Gaining Optimal Asthma Control study. Am J Respir Crit Care Med. 2004;170:836-44. This is a 1-year, randomized, stratified, double-blind, parallel-group study (n=3,421) of patients with uncontrolled asthma comparing the addition of LABA vs escalating steroidin achieving two rigorous, composite, guideline-based measures of control: totally and well-controlled asthma. Control was achieved more rapidly and at a lower corticosteroid dose with salmeterol/fluticasone versus fluticasone alone.

Peters SP, Kunselman SJ, Icitovic N, et al. for the National Heart, Lung, and Blood Institute Asthma Clinical Research Network. Tiotropium bromide step-up therapy for adults with uncontrolled asthma. N Engl J Med 2010;363:1715-26. The TALC study showed that, in patients with asthma inadequately controlled by low-moderate dose inhaled corticosteroid therapy, the addition of long-acting anticholinergic therapy was superior to corticosteroid dose escalation and noninferior to long-acting beta-agonist therapy. However, the study was not powered to compare the effect on exacerbations.

Hanania NA, Alpan O, Hamilos, et al. Omalizumab in severe allergic asthma inadequately controlled with standard therapy: a randomized trial. Ann Intern Med 2011;154:573-82. In this multicenter RCT (n=850), of patients with inadequately controlled asthma despite high-dose ICS and LABA, the addition of omalizumab reduced the one-year exacerbation rate (NNT of 5 to prevent

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one exacerbation/year) and reduced use of rescue albuterol by 0.27 puffs/day.

Gamble J, Stevenson M, McClean E, et al. The prevalence of nonadherence in difficult asthma. Am J Respir Crit Care Med 2009;180:817-22. In a patient population referred for specialist care in the setting of refractory asthma, 35% of patients filled fewer than half of their prescriptions for inhaled corticosteroids. The nonadherent patients had a lower asthma-specific quality of life that was clinically significant. Highlighting an important and often overlooked factor in asthma refractoriness, these findings are supported by high nonadherence rates seen in large clinical trials.

Mastronade JG, Anthonisen NR, Castro M, et al. Efficacy of esomeprazole for treatment of poorly controlled asthma. N Engl J Med 2009; 360:1487-99. 412 patients with minimal or no reflux symptoms and poorly controlled asthma despite moderate to high dose of inhaled corticosteroids to high-dose esomeprazole. Subjects underwent 24-hour esophageal pH studies prior to starting proton pump inhibitor. The study is noteworthy for finding no improvement in asthma control in this population, regardless of the presence of asymptomatic gastroesophageal reflux.

Castro M, Rubin AS, Laviolette M, et al. Effectiveness and safety of bronchial thermoplasty in the treatment of severe asthma: a multicenter, randomized, double-blind, sham-controlled clinical trial. (AIR2 Trial) Am J Respir Crit Care Med 2010;181:116-24. The AIR2 trial was the first large scale randomized study of bronchial thermoplasty to include a sham control. 288 patients with asthma symptoms despite standard therapy (high dose ICS + LABA) were included. During the 12 month follow up, the treatment group had a lower number of adverse respiratory events, severe exacerbations, emergency department visits, and hospitalizations, as well as a greater number (81%) of subjects reporting improvement in AQLQ. Notably, 63% of control subjects also reported clinically significant (>0.5) improvement in AQLQ. During treatment, 8.4% of patients in the treatment group were hospitalized for respiratory symptoms compared to 2.0% in te sham group.

Edelman JM, Turpin JA, Bronsky EA, et al. Oral montelukast compared with inhaled salmeterol to prevent exercise- induced bronchoconstriction. A randomized, double-blind trial. Ann Intern Med 2000;132:97-104. Study found leukotriene blockade has equal efficacy to a beta-agonist for the prevention of EIB and that daily administration is not associated with a reduction in efficacy that may be seen with daily dosing of long-acting beta agonists.

COMMUNITY ACQUIRED PNEUMONIA:

Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44 Suppl 2:S27-72. An influential new consensus statement from two major societies.

Fine MJ, Auble TE, Yealy DM et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997;336:243-50. This oft-cited prediction rule, the Pneumonia Severity Index (PSI), incorporates patient demographics, co-morbidities, vitals, labs, and chest film to identify patients likely to do well with outpatient treatment of CAP.

Lim WS, Lewis S, Macfarlane JT. Severity prediction rules in community acquired pneumonia: a validation study. Thorax 2000;55:219-23. The CURB-65 (also validated as the CRB-65 when BUN is unavailable) is simpler to use than the PSI but is not as sensitive for predicting mortality.

Mittl RL, Schwab RJ, Duchin JS et al. Radiographic resolution of community-acquired pneumonia. Am J Respir Crit Care Med 1994;149:630-5. Prospective follow-up of both inpatients and outpatients with diagnosis of CAP is cited as a guide for when to look for endobronchial lesions in the setting of slowly clearing pneumonia. The study found age and multilobar disease were independent predictors of delayed resolution. Radiographic resolution seen in 51% at 2 weeks, 67% at 4 weeks, and 90% at 12 weeks.

Schuetz P, Christ-Crain M, Thomann R. Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial. JAMA 2009;302:1059-66. 1359 patients with lower respiratory tract infections in 6 Swiss academic hospitals were randomized to a treatment algorithm based on procalcitonin (PCT) levels or to treatment based on current evidence based guidelines. PCT-guided therapy reduced total antibiotic exposure without any change in adverse outcomes. Controversy exists regarding the unusually high prevalence of “severe” pneumonia by PSI

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score, and that reduction in exposure was primarily due to reduced duration of antibiotics rather than avoidance.

COPD:

Global strategy for the diagnosis, management, and prevention of COPD: GOLD workshop summary. http://www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html

Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med 2011;155:179-91.

Niewoehner DE, Rice K, Cote C, et al. Prevention of exacerbations of chronic obstructive pulmonary disease with tiotropium, a once-daily inhaled anticholinergic bronchodilator. Ann Intern Med 2005;143:317-26. A large multi-center RCT of VA patients with moderate to severe COPD (mean baseline FEV1 36%) found tiotropium reduced the proportion of patients with 1 or more exacerbations during 6 months of treatment vs. placebo (27.9 % vs. 32.3 %). These results support using tiotropium in COPD patients with moderate to severe obstruction and frequent exacerbations.

Burge PS, Calverley PMA, Jones PW, et al. Randomized, double blind, placebo-controlled study of fluticasone proprionate in patients with moderate to severe COPD: the ISOLIDE trial. BMJ 2000;320:1297-1303. Use of inhaled steroid did not improve the rate of decline in FEV1 compared to placebo. The fluticasone group had a median of 0.99 exacerbations/yr vs. 1.32/yr in the placebo arm. Response to oral steroids given in the run-in phase was not predictive of subsequent benefit from inhaled steroid.

The Lung Health Study Research Group. Effect of inhaled triamcinolone on the decline in pulmonary function in COPD. N Engl J Med 2000;343:1902-09. Randomized, controlled study followed over 1000 patients for an average of 4.5 yrs and found no difference in rate of decline in FEV1 in the inhaled steroid group. Patients using triamcinolone had, by some measures, fewer symptoms, but also had a greater rate of decline in bone density that is of unknown clinical significance.

Calverley PM, Anderson JA, Celli B, et al. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. N Engl J Med 2007; 356:775-89. The TORCH study randomized over 6,000 patients with baseline FEV1 < 60% predicted to placebo vs. salmeterol alone vs. fluticasone alone vs. a combination of salmeterol and fluticasone over 3 years. Compared to placebo, patients receiving combination therapy had a 0.9% annual reduction in mortality (p = .052). Use of salmeterol, fluticasone, or a combination of the 2 reduced the frequency of exacerbations, but p was >.10 for all 3 for reducing risk of COPD-related death. All-cause mortality and COPD-related death were lower with combination therapy than fluticasone alone (p = .007 and .008, respectively).

Tashkin DP, Celli B, Senn S, et al. A 4-year trial of tiotropium in chronic obstructive pulmonary disease. (UPLIFT Trial) N Engl J Med 2008; 359:1543-54. The UPLIFT study added tiotropium or placebo to 5,993 COPD patients’ baseline regimen. Nearly half were already on a combination inhaled corticosteroid/long-acting B-agonist and over 70% were on an inhaled steroid or long-acting B-agonist. The addition of tiotropium reduced exacerbations (median delay to first exacerbation of 16.7 months vs. 12.5 months for placebo), but did not affect the rate of decline in FEV1. In contrast to the findings of a recent meta-analysis (Singh S et al. JAMA 2008;300:1439), tiotropium was not associated with increased risk of cardiovascular morbidity or mortality.

Wedzicha JA, Calverley PM, Seemungal TA, et al. The prevention of chronic obstructive pulmonary disease exacerbations by salmeterol/fluticasone propionate or tiotropium bromide. (INSPIRE Trial) Am J Respir Crit Care Med 2008; 177:19-26. 2-year INSPIRE study randomized 1,323 patients with mean baseline FEV1 39% predicted to the above arms and found no difference in exacerbation rate, but also had a higher proportion of patients randomized to tiotropium withdraw from the study (42 vs. 34% in the salmeterol-fluticasone group, p = .005). Although a greater proportion of patients receiving salmeterol-fluticasone had pneumonia (8 vs. 4%), this group had lower all-cause mortality (3 vs. 6%, p = .03). However, this mortality benefit may be attributable to incomplete follow-up of patients who withdrew from the study.

Vogelmeier C, Hederer B, Glaab T, et al. Tiotropium versus salmeterol for the prevention of exacerbations of COPD. N Engl J Med 2011;364:1093-103. In a prospective, randomized, double-blind, double-dummy trial, over 7000 patients who had had at least one exacerbation over the previous year were randomized to receive either tiotropium or salmeterol for one year. They continued on their other therapies, including corticosteroids, as determined by their provider, but any prescribed anticholinergic or long-acting β2-agonist was discontinued. The primary endpoint was time to first exacerbation of COPD, which was increased by 42 days in the tiotropium group (p<0.001). In clinical practice, inhaled corticosteroids are often prescribed in combination with a long-acting β2-

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agonist—regardless of whether an anticholinergic is prescribed—though this study offers some evidence that perhaps anticholinergic therapy would be more appropriate as initial long-acting bronchodilator therapy.

Albert RK, Connett J, Bailey WC, et al. Azithromycin for prevention of exacerbations of COPD. N Engl J Med 2011;365:689-98. In a large study of patients who required continuous oxygen or had required systemic steroids in the last year and had had at least one prior exacerbation, but who were stable for at least a month prior to the study, the use of daily azithromycin was found to increase the time to subsequent exacerbation from six months to nine months. An audiology-confirmed hearing decrement occurred in 25% of study patients and 20% of placebo patients (p=0.04).

Niewoehner DE, Erbland ML, Deupree RH, et al. Effect of systemic glucocorticoids on exacerbations of COPD. N Engl J Med 1999;340:1941-7. Multicenter, double blind, placebo- controlled study found modest benefit to use of high-dose intravenous steroids. Steroid group had fewer treatment failures (combined endpoint of death, need for intubation, readmission, or intensification of pharmacologic therapy), and shorter hospital stays, but the primary benefit was in decreasing the need to intensify therapy with use of open-label steroids. No benefit from steroids was present at 6 months of f/u, and 2 week and 8 week courses were equally effective.

Anthonisen NR, Manfreda J, Warren CPW et al. Antibiotic therapy in exacerbations of COPD. Ann Intern Med 1987;106:196-204. Famous study often cited by proponents of antibiotic use for COPD exacerbations. Randomized, blinded, controlled study found use of antibiotics in the presence of increased dyspnea, increased sputum production, and increased sputum purulence improved outcomes. The improvement was no longer significant, however, after controlling for use of oral steroids.

Daniels JM, Snijders D, de Graaff CS, et al. Antibiotics in addition to systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2010;181:150-7. This study attempts to address the perennial question of the utility of antibiotics in acute COPD exacerbations. In an RCT of 265 exacerbations that excluded patients with fever and radiographic infiltrates, the addition of 7 days of doxycycline to prednisone did not lead to a significant improvement in 30-day clinical response, which was the primary endpoint, though secondary outcomes of clinical cure and clinical success at day 10 were improved in the antibiotic arm. The negative findings with respect to the primary endpoint challenge the reflex use of antibiotics in this setting, though the exclusion of severe exacerbations, patients with objective evidence of infection, and concern about doxycycline resistance leave unanswered the question of when antibiotics are truly indicated.

NOTT group. Continuous or nocturnal oxygen therapy in hypoxemic COPD. Ann Intern Med 1980;93: 391-8. Famous multicenter study showing use of continuous oxygen therapy (>17 hr/d) resulted in lower mortality than use of nocturnal therapy (12 hr/d) in pts. with PaO2 55 mmHg or PaO2 59 mmHg and pulmonary hypertension, right-sided failure, or Hct 55%.

MRC Working Party. Long-term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. Lancet 1981;8222:681-5. Another well known study showing improved survival with continuous oxygen in hypoxemic COPD patients.

Rice KL, Dewan N, Bloomfield HE, et al. Disease management program for chronic obstructive pulmonary disease: a randomized controlled trial. Am J Respir Crit Care Med 2010;182:890-6. The relatively simple provision of a 1- to 1.5-hour information session, individual action plan with home courses of antibiotics and prednisone, and a case manager led to a marked reduction in hospitalizations and ED visits, with a NNT of 3 to prevent one event per patient-year.

NETT Research Group. Patients at high risk of death after lung-volume-reduction surgery. N Engl J Med 2001;345:1075-83. Early results from NETT found a 16% 30-day mortality following LVRS in the 69 patients with FEV1 < 20% predicted AND homogenous disease per CT OR DLCO < 20% predicted. This population had higher overall mortality than comparable patients randomized to medical treatment. Survivors of LVRS had modest improvements in exercise tolerance and FEV1, but similar measures of quality of life.

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Fishman A, Martinez F, Naunheim K, et al. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema: NETT Research Group. N Engl J Med 2003;348:2059-73. After excluding the 140 pts identified as having high risk of mortality based on the above interim analysis, a greater proportion of LVRS patients had improved exercise tolerance compared to the medical therapy arm (16% vs. 3%), but there was no survival advantage after 24 months. Subgroup analysis found patients with predominantly upper lobe disease and low exercise capacity had improved mortality, while patients with non-upper lobe emphysema and high exercise capacity had higher mortality following LVRS compared to medical therapy.

Traver GA, Cline MG, Burrows B. Predictors of mortality in COPD: A 15-year f/u study. Amer Rev Res Dis 1979;119:895-902. Ubiquitously cited study looking at FEV1 and survival. After controlling for age, the FEV1 after bronchodilator was the best predictor of survival, but was less predictive in patients over 65. The observed wide variability in survival of individual patients with similar initial FEV1 values has important implications for patients considering surgical treatments for their COPD.

Celli BR, Cote CG, Marin JM, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med 2004;350:1005-12. This study found a combination of BMI, FEV1, modified MRC dyspnea scale, and 6 minute walk (i.e. the BODE index) was a better predictor of mortality than FEV1 alone. The BODE index may prove to be a better guide than FEV1 for assessing the efficacy of new treatments and adjusting the aggressiveness of therapy.

SYMPTOMS:

Pratter MR, Brightling CE, Boulet LP, Irwin RS. An empiric integrative approach to the management of cough: ACCP evidence-based clinical practice guidelines. Chest. 2006; 129(1 Suppl):222S-231S. Excellent review of algorithms that provide a "road map" for managing acute, subacute, and chronic cough.

Birring SS. Controversies in the evaluation and management of chronic cough. Am J Respir Crit Care Med 2011;183:708-15. This helpful review focuses on some of the more frustrating clinical questions regarding the persistent chronic cough

Lordan JL, Gascoigne A, Corris PA. The pulmonary physician in critical care * Illustrative case 7: Assessment and management of massive haemoptysis. Thorax. 2003; 58:814-9. A practical review of managing massive hemoptysis

ILD:

American Thoracic Society/European Respiratory Society international multidisciplinary consensus classification of the idiopathic interstitial pneumonias. Am J Respir Crit Care Med 2002;165:277-304. Written to standardize the diagnostic criteria and terminology for idiopathic interstitial pneumonias, this article nicely summarizes the clinical, radiologic, and histologic features of the ILD alphabet soup.

Lazor R, Vandevenne A, Pelletier A, et al. Cryptogenic organizing pneumonia: characteristics of relapses in a series of 48 patients. Am J Respir Crit Care Med 2000; 162:571-7. This retrospective case series provides insight on the clinical course of COP and has had a large influence on the way corticosteroids are used to treat COP. 58% of patients experienced a relapse, 82% of which occurred within 1 year of the initial episode. Two-thirds of patients were on corticosteroids at the time of first relapse; only 1 patient was on > 20 mg/day of prednisone. Delayed treatment was a risk factor for relapse. Relapses did not affect longer term outcome.

Raghu G, Collard HR, Egan JJ, et al. An official ATS/ERS/JRS/ALAT statement: idiopathic pulmonary fibrosis: evidence-based guidelines for diagnosis and management. Am J Respir Crit Care Med 2011;183:788-824.

Demedts M, Behr J, Buhl R, et al, IFIGENIA Study Group. High-dose acetylcysteine in idiopathic pulmonary fibrosis. N Engl J Med. 2005; 353:2229-42. Multi-center, double-blind, randomized, placebo-controlled study (N=182) which determined (after one year) that high-dose oral acetylcysteine added to standard therapy (prednisone and azathioprine) resulted in modest benefit in terms of preserving vital capacity and DLCO but offered no survival advantage. A large proportion of patients dropped out of the study and there is concern that acetylcysteine prevented azathioprine toxicity rather than treated IPF.

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Baughman RP, Costabel U, du Bois RM. Treatment of sarcoidosis. Clin Chest Med 2008; 29:533-48. Offers some additional information since the 1999 ATS/ERS statement on sarcoidosis. Additional articles in this issue of Clin Chest Med cover other aspects of sarcoidosis.

Tashkin DP, Elashoff R, Clements PJ, et al. Effects of 1-year treatment with cyclophosphamide on outcomes at 2 years in scleroderma lung disease. Am J Respir Crit Care Med 2007;176:1026-1034. This follow-up study to the one cited above found the benefits of cyclophosphamide treatment extended to 6, but not 12, months after completion of treatment. Benefit was greatest in patients with a greater burden of fibrotic disease. These results provide a rationale for subsequent consolidation therapy with a less toxic agent such as mycophenolate mofetil.

Travis WD, Hunninghake G, King TE, et al. Idiopathic nonspecific interstitial pneumonia: report of an American Thoracic Society project. Am J Respir Crit Care Med; 2008;177:1338-47. Based on review by a panel of experts, idiopathic NSIP does exist as a distinct clinical entity. However, diagnosis appears challenging, as only 67 of 193 previously reported cases of NSIP were determined to have NSIP by the panel using a combination of clinical, radiologic, pathologic assessment.

Lung Cancer

Lababede O, Meziane M, Rice T. Seventh edition of the cancer staging manual and stage grouping of lung cancer: quick reference chart and diagrams. Chest 2011;139:183-9.

Gould et al. Evaluation of Individuals with Pulmonary Nodules: When is it lung cancer? Chest 2013; 143 (5):e93S-e120S.

Rivera et al. Establishing the Diagnosis of Lung Cancer. Chest 2013; 143 (5):e142S-e165S.

Silvestri et al. Methods for Staging Non-small cell Lung Cancer. Chest 2013; 143 (5):e211S-e250S.

Chang et al. The Use and Misuse of Positron Emission Tomography in Lung Cancer Evaluation. Clinics in Chest Medicine 2011; 32(4):749-762.

Annema JT, van Meerbeeck JP, Rintoul RC, et al. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial. JAMA 2010;304:2245-52. An RCT of EUS/EBUS/surgical staging vs. surgical staging alone in 241 patients with potentially resectable NSCLC found a sensitivity and NPV of 94% and 93% with the combined approach, a substantial improvement over surgical staging alone (79% and 86%). In the 123 patients assigned to the combined modality arm, endosonography identified mediastinal metastases in half, precluding the need for mediastinoscopy, and in the 65 patients with negative EUS/EBUS-FNA, mediastinoscopy identified mets in only six, highlighting the high sensitivity of the endosonographic approach alone. The study was performed at tertiary centers using conscious sedation for endosonography.

National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011;365:395-409. This large trial compared annual CT versus CXR over two years (baseline, one-year, and two-year screening). Analyzing only those who underwent at least one screening test, the absolute risk reduction for lung cancer-associated mortality was 0.3% (relative reduction of 20%), yielding a number needed to screen to prevent one death of approximately 320, with a CT false positive rate of 96.4%. Cost-effectiveness analyses and evaluation of the impact of invasive procedures related to false-positive results are not yet known.

Mycobacterial Infections:

Griffith DE, Aksamit T, Brown-Elliott BA, et al. The official ATS/IDSA statement: Diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med 2007; 175:367-416. More comprehensive than its 1997 predecessor, this statement provides a general overview of NTM pathogenesis, presentation, and diagnosis as well as easily retrieved treatment recommendations on specific organisms.

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Updated guidelines for using interferon gamma release assays to detect Mycobacterium tuberculosis infection — United States, 2010. Centers for Disease Control and Prevention. MMWR 2010;59:1-25. Offers the latest guidelines on the use of IGRAs in the diagnosis of TB. Access at the CDC website.

International Union against Tuberculosis Committee on Prophylaxis. Efficacy of various durations of isoniazid preventive therapy for tuberculosis: five years of follow-up in the IUAT trial. Bull WHO 1982;60:555-64. Noteworthy for being the only study of the efficacy and safety of different durations of INH prophylaxis.

Jereb JA, Goldberg SV, Powell K, et al. Recommendations for use of an isoniazid-rifapentine regimen with direct observation to treat latent Mycobacterium tuberculosis infection. MMWR Morb Mortal Wkly Rep 2011;60:1650-3. A significant advancement in the treatment of latent tuberculosis due to its three-month duration, this advantage may be partially offset by rifapentine shortages, drug costs, the need for directly observed therapy, and a high daily pill burden.

Cystic Fibrosis :

Flume PA, Mogayzel PJ Jr, Robinson KA, et al. Cystic fibrosis pulmonary guidelines: treatment of pulmonary exacerbations. Am J Respir Crit Care Med 2009; 180:802-8. This document offers graded recommendations for management of exacerbations, but is most noteworthy for highlighting the lack of evidence guiding many fundamental aspects of care.

Flume PA, O’Sullivan BP, Robinson KA, et al. Cystic fibrosis pulmonary guidelines: chronic medications for maintenance of lung health. Am J Respir Crit Care Med 2007; 176:957-969. This document offers graded recommendations for medication use according to patient age and severity of lung disease. It also nicely summarizes areas of clinical uncertainty.

Ramsey BW, Davies J, McElvaney NG, et al. A CFTR potentiator in patients with cystic fibrosis and the G551D mutation. N Engl J Med 2011;365:1663-72. The first study to show a substantial benefit from a therapy targeting the underlying cause of clinical CF, this study showed an absolute increase in predicted FEV1 of 10% in patients with at least one G551D-CFTR mutation receiving ivacaftor (VX-770), a CFTR potentiator, compared to a small FEV1 decline in the placebo group, over a study period of approximately six months. Ramsey BW, Pepe MS, Quan JM, et al. Intermittent administration of inhaled tobramycin in patients with cystic fibrosis. N Engl J Med 1999;340:23-9. Study found use of TOBI on alternating months improved lung function, decreased bacterial burden, and decreased the relative risk of hospitalization. The rate of acquired tobramycin resistance was about 7% over 24 weeks.

Saiman L, Marshall BC, Mayer-Hamblett N, et al. Azithromycin in patients with cystic fibrosis chronically infected with pseudomonas aeruginosa. JAMA 2003;290:1749-56. Large multicenter RCT of 6 months duration found chronic azithromycin resulted in a 4.4% improvement in FEV1% predicted compared to a 1.8% decline in placebo. The azithromycin group had fewer exacerbations and gained more weight. Elkins MR, Robinson M, Rose BR, et al. A controlled trial of long-term inhaled hypertonic saline in patients with cystic fibrosis. N Engl J Med 2006; 354:229-40. This study of 164 children and adults with CF found the combination of bronchodilator and 7% saline neb bid had only a modest impact on pulmonary function but reduced exacerbations (76% exacerbation free vs. 62% placebo, p = .03). These results may not be applicable to patients on more aggressive baseline regimens than the study population.

Retsch-Bogart GZ, Quittner AL, Gibson RL, et al. Efficacy and safety of inhaled aztreonam lysine for airway Pseudomonas in cystic fibrosis. Chest 2009;135:1223-32. This is the largest published study of inhaled aztreonam, which was recently FDA-approved. 164 children and adults with moderate-to-severe CF lung disease and pseudomonas infection were randomized to receive inhaled aztreonam (75 mg TID) or placebo for 28 days. The treatment group had no increased adverse events, but had a reduction in productive cough (25% vs 12.5%) as well as significant improvement in multiple CFQ-R scales. No difference in treatment emergent infections was observed. This study demonstrated short term safety and benefits. Results of longer-duration studies are forthcoming.

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Aaron SD, Vandemheen KL, Ferris W, et al. Combination antibiotic susceptibility testing to treat exacerbations of cystic fibrosis associated with multiresistant bacteria: a randomised, double-blind, controlled clinical trial. Lancet 2005; 366:463-71. This study of 132 CF patients found selection of intravenous antibiotics based on multiple combination bactericidal susceptibility testing did not reduce the time to next exacerbation compared to antibiotic selection based on conventional culture and sensitivity tests and there was no difference in the rate of treatment failure.

OCCUPATIONAL LUNG DISEASE:

Nicholson PJ, Cullinan P, Taylor AJ, et al. Evidence-based guidelines for the prevention, identification, and management of occupational asthma. Occup Environ Med 2005;62:290-9. This comprehensive review gives strong evidence behind classic admonitions, including those to reduce asthmagens at the source and to provide ample surveillance.

Burge PS, O’Brien IM, Harries MG. Peak flow rate records in the diagnosis of occupational asthma due to isocyanates. Thorax 1979;34:317-24. Landmark study was the first to show peak flow is a suitable alternative to provocation testing in the diagnosis of OA.

Brooks SM, Weiss MA, Bernstein IL. Reactive airways dysfunction syndrome (RADS): persistent asthma syndrome after high-level irritant exposures. Chest 1985;88:376-84. Landmark article describing 10 patients in which the term “RADS” was coined. In the majority of cases respiratory symptoms and hyper reactivity persisted for greater than 1 year after a large exposure to vapor, fumes, or smoke.

Zock JP, Plana E, Jarvis D, et al. The use of household cleaning sprays and adult asthma. Am J Respir Crit Care Med 2007; 176:735-41. This longitudinal study of over 3,500 individuals free of asthma at baseline is noteworthy for finding regular, non-professional use of household cleaning sprays is associated with a RR of 2.1 of new physician-diagnosed asthma.

Tarlo SM, Balmes J, Balkissoon R, et al. Diagnosis and management of work-related asthma: American College of Chest Physicians consensus statement. Chest 2008;134:1S-41S. This update to the 1995 statement is derived primarily from consensus among a panel of experts, as there are no RCTs studying the diagnosis and treatment of work-related asthma. It provides practical guidance for clinicians that do not routinely see patients with work-related asthma.

Adverse effects of crystalline silica exposure. American thoracic society committee of the scientific assembly on environmental occupational health. Am J Respir Crit Care Med 1997; 155:761-8. Reviews the epidemiology and prevention of silica-associated lung diseases including silicosis, asthma, tuberculosis, and extrapulmonary diseases. This document is also available in UpToDate™.

McCreanor J, Cullinan P, Nieuwenhuijsen MJ, et al. Respiratory effects of exposure to diesel traffic in persons with asthma. N Engl J Med 2007; 357:2348-58. This randomized crossover study of patients with mild to moderate asthma found greater exposure to air pollution from road traffic resulted in greater decrements in lung function and greater inflammation, thus serving as confirmation of epidemiologic evidence linking traffic exposure to decrements in lung function among asthmatics.

Künzli N, Bridevaux P-O, Liu L-J, et al. Traffic-related air pollution correlates with adult-onset asthma among never-smokers. Thorax 2009; 64:664-70. There is strong evidence that traffic-related air pollution places a causal role in childhood asthma, but less is known about risk in adults. This Swiss cohort study, which used particularly rigorous methodology, confirmed an association between adult-onset asthma and exposure to home outdoor traffic-related particulate matter in never smokers. Particulate matter concentrations improved during the 10-year study and there were only 41 new cases in a study population of 2,725.

PRE-OP PULMONARY EVALUATION:http://chestjournal.chestpubs.org/content/104/5/1378.long

Colice GL, Shafazand S, Griffin JP, et al. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2nd edition). Chest 2007; 132(3 Suppl):161S-77S. Updated summary of the use of PFTs, split function tests, and cardiopulmonary exercise tests in the assessment of lung resection candidates

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PLEURAL DISEASES

Davies CWH, Kearney SE, Gleeson FV, Davies RJO. Predictors of outcome and long-term survival in patients with pleural infection. Am J Respir Crit Care Med 1999; 160:1682-7. In the absence of frank empyema, tube thoracostomy plus lytics had a PPV of 93% for successful treatment (i.e. no need for surgery). The presence of pus had a PPV for failure of medical management of 26%. Fluid characteristics, effusion size, and degree of pleural thickening were not predictive of medical failure. Study didn't consider presence of loculations or assess long-term outcomes.

Rahman NM, Maskell NA, Davies CWH, et al. The relationship between chest tube size and clinical outcome in pleural infection. Chest 2010;137:536-43. This post hoc analysis of a U.K. trial of intrapleural streptokinase in 405 patients with intrapleural infection found use of smaller chest tubes did not increase the risk of death or need for surgery, including in the subset of patients with visibly purulent fluid. Furthermore, use of a 15 French or smaller tube reduced the proportion of patients experiencing moderate to severe pain by 50%. Of note, chest tube size and method of insertion were at the discretion of the treating team and only 32% of patients completed the pain assessment. Roberts ME, Neville E, Berrisford RG, et al. for the British Thoracic Society Pleural Disease Guideline Group. Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65(Suppl 2):ii32-ii40 MacDuff A, Arnold A, Harvey J for the British Thoracic Society Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65(Suppl 2):ii18-ii31

PULMONARY EMBOLISM

Moores LK, King CS, Holley AB. Current approach to the diagnosis of acute nonmassive pulmonary embolism. Chest 2011;140:509-18. This discussion of an approach to diagnosis is interesting in its emphasis on the use of V/Q scan—rather than CTA—as the initial test of choice in patients with a normal CXR and without signs or symptoms of DVT, a recommendation that is based on an increasing focus on the avoidance of CT radiation exposure whenever possible.

van Belle A, Buller HR, Huisman MV, et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA 2006; 295:172-9. This study classified 3,306 patients as “PE likely” or “PE unlikely” based on a dichotomized version of Wells criteria. “PE unlikely” plus a negative D-dimer sufficiently ruled out PE without further testing (0.5% with PE diagnosis in subsequent 3 months). Patients with “PE likely” or a positive D-dimer underwent CT angiogram. 95% of patients with a negative CT had anticoagulation withheld without further testing and 1.3% were subsequently diagnosed with PE over 3 months. 88% of scans were multidetector row studies.

Anderson DR, Kahn SR, Rodger MA, et al. Computed tomographic pulmonary angiography vs. ventilation-perfusion lung scanning in patients with suspected pulmonary embolism. JAMA 2007; 298:2743-53. This RCT found that of 531 patients with a positive d-dimer but negative CT, only 1.3% had a positive lower extremity ultrasound. Of note, patients randomized to CT were more likely to be diagnosed with PE than with VQ scanning (19.2% vs. 14.2%), but there was no significant difference in the diagnosis of venous thromboembolism in the subsequent 3-month follow-up period. This raises the possibility of false-positive results or identification of clinically insignificant clot with CT. (see also Stein PD, et al study below)

Stein PD, Fowler SE, Goodman LR, et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med 2006; 354:2317-27. The much-anticipated PIOPED II study of 824 patients found CT angiogram had a sensitivity of 83% and specificity of 96%, excluding the 6% with poor quality images. The sensitivity improved to 90% with addition of CT venography. The positive predictive value was 96% when the result was concordant with a high or low clinical suspicion, but CT was non-diagnostic if there was discordance. For instance, there were 42% false-positives among patients with low clinical suspicion and a positive scan, and 40% false negatives among patients with high clinical probability but negative scan. CTs were primarily performed with 4-slice scanners. The results of a subsequent RCT by Anderson DR et al (JAMA 2007;298:2743-53) also suggest CT angio may yield false-positive results or diagnose clinically insignificant clot.

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Schulman S, Granqvist S, Holmstrom M, et al. The duration of oral anticoagulation after a second episode of venous thromboembolism. N Engl J Med 1997; 336:393-8. Randomized trial comparing anticoagulation for 6 months compared to indefinitely in patients with a history of recurrent embolism (including idiopathic and with risk factors). Recurrent thromboembolism occurred in 21% of patients in the 6-month group and in 2.7% of the indefinite group after 4 yrs of f/u. Major bleeding occurred in 5% of patients, of whom 18% died.

Agnelli G, Prandoni P, Becattini C, et al. Extended oral anticoagulant therapy after a first episode of pulmonary embolism. Ann Intern Med. 2003; 139:19-25. Randomized, non-blinded study of extending anticoagulation beyond 3 months in patients with first episode of idiopathic PE and PE associated with temporary risk factors. Extending anticoagulation in patients with idiopathic PE from 3 to 12 months only delayed onset of what proved to be a high recurrence rate (4-5% per patient-year once off anticoagulation). A more recent study by Campbell IA et al. BMJ 2007;334;674 reported similar findings. These studies highlight the need for new ways of identifying patients at high risk of recurrence to allow selective use of life-long anti-coagulation.

Ridker PM, Goldhaber SZ, Danielson E, et al. Long-term, low-intensity warfarin therapy for the prevention of recurrent venous thromboembolism. N Engl J Med 2003; 348:1425-34. The PREVENT study is often cited as the basis for using chronic low-dose anticoagulation to prevent recurrence of idiopathic venous thromboembolism following initial full course of treatment, particularly in patients with erratic INR results. The study compared placebo to target INR of 1.5 to 2.0 in 508 patients and found higher recurrence in the placebo than the warfarin group (7.2 vs. 2.6/100 patient-years). There was no significant difference in major hemorrhage events between groups.

Kearon C, Ginsberg JS, Kovacs MJ, et al. Comparison of low-intensity warfarin therapy with conventional-intensity warfarin therapy for long-term prevention of recurrent venous thromboembolism. N Engl J Med 2003; 349:631-9. Findings of the ELATE study suggest some advantage to conventional warfarin dosing. ELATE randomized 738 patients following treatment of idiopathic venous thromboembolism to either long-term warfarin with target INR of 1.5 to 1.9 or to a target of 2.0 to 3.0 and found a modest reduction in recurrent thromboembolic events in the conventional group (0.7 vs. 1.9/100 person-years). The 2 groups had similar risk of major bleeding, and this study is cited by advocates for conventional dosing for long-term prophylaxis in this population, particularly among patients with consistent warfarin dose requirements.

Konstantinides S, Geibel A, Heusel G, et al. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med 2002; 347:1143-50. This randomized, double blind study is cited by both advocates and those opposed to lytic therapy in submassive PE. The study found lytics did not improve mortality. Patients randomized to lytics were significantly less likely than the placebo group to require escalation of therapy, which primarily entailed administration of lytics. The indication for rescue therapy was worsening respiratory symptoms, short of intubation, two-thirds of the time.

Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal DVT. N Engl J Med 1998; 338:409-15. This is the only randomized trial involving filters. All patients were aniticoagulated and LMW and unfractionated heparin were equally effective. 4.8% of patients receiving anticoagulation alone had PE vs. 1.1% in filter + anticoagulation group at study day 12. There was no difference in rate of PE after anticoagulation was discontinued, but the filter group had significantly more recurrent DVT.

Mayer E, Jenkins D, Lindner J, et al. Surgical management and outcome of patients with chronic thromboembolic pulmonary hypertension: results from an international prospective registry. J Thorac Cardiovasc Surg 2011;141:702-10. This description of experience within an international, multi-institutional setting offers a comparison with the San Diego experience described in the article y Jamieson et al. Preoperative PVR was somewhat lower in this group, circulatory arrest time was the same, and one-year mortality was 7%. An interesting discussion, including a member of the San Diego group, follows the references.

Jamieson SW, Kapelanski DP, Sakakibara N, et al. Pulmonary endarterectomy: experience and lessons learned in 1,500 cases. Ann Thorac Surg 2003; 76:1457-64. Summarizes entire UCSD experience with thromboendarterectomy. The most recent 500 cases (through 12/02) are discussed in greater detail. 30-day mortality in this group was 4.4%, which varied according to type of thrombotic

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lesion and preoperative hemodynamics.

Leung AN, Bull TM, Jaeschke R, et al. An official American Thoracic Society/Society of Thoracic Radiology clinical practice guideline: evaluation of suspected pulmonary embolism in pregnancy. Am J Respir Crit Care Med 2011;184:1200-8. This clinical practice guideline offers useful recommendations, and includes an emphasis on favoring V/Q scan as the initial step in diagnosis in pregnant women suspected of having PE who have no leg symptoms and a normal CXR. The recommendation focuses especially on the future malignancy risk posed to young mothers undergoing a potentially avoidable chest CT. With abdominal shielding, fetal risk may be less, but is also accounted for in this recommendation.

PULMONARY HYPERTENSION:

McLaughlin VV, Archer SL, Badesch DB, et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association: developed in collaboration with the American College of Chest Physicians, American Thoracic Society, Inc., and the Pulmonary Hypertension Association. This document is noteworthy for containing the latest consensus statement on the classification, evaluation, treatment, and monitoring of patients with pulmonary hypertension. Circulation 2009; 28:119:2250-94.

Arcasoy SM, Christie JD, Ferrari VA, et al. Echocardiographic assessment of pulmonary hypertension in patients with advanced lung disease. Am J Respir Crit Care Med 2003; 167:735-40. The cardiology literature indicates echocardiography-derived estimates of pulmonary artery pressures are accurate. This study found 52% of echo estimates were inaccurate (off by > 10 mmHg) in 166 lung transplant candidates and the difference was > 20 mmHg in 28%. In patients without hypertension, echo was more likely to overestimate pressures while in patients with pulmonary hypertension; it was as likely to over as underestimate. Accuracy and ability to obtain an estimate varied with the underlying disease.

Fisher MR, Forfia PR, Chamera E, et al. Accuracy of Doppler echocardiography in the hemodynamic assessment of pulmonary hypertension. Am J Respir Crit Care Med 2009; 179:615-21. This prospective study of 65 patients undergoing right-heart catheterization for the diagnosis or management of pulmonary hypertension extends the findings of Arcasoy et al. above to patients without end-stage lung disease. Echo over or underestimated pulmonary artery pressure by > 10 mm Hg 52% of the time. The majority of patients had pulmonary arterial hypertension (WHO Group 1).

Rich S, Kaufman E, Levy PS. The effect of high doses of calcium-channel blockers on survival in primary pulmonary hypertension. N Engl J Med 1992;327:76-81. Study with suboptimal design but convincing hemodynamic data found improved survival and is the basis for use of CCBs in patients with a good response to vasodilators.

Sitbon O, Humbert M, Jais X, et al. Long-term response to calcium channel blockers in idiopathic pulmonary arterial hypertension. Circulation 2005; 111:3105-3111. This retrospective analysis found that only 54% of the patients who had initial vasoreactivity and were placed on calcium channel blockers had a favorable long-term response. This finding prompted a revision in the consensus definition of a favorable response to acute vasodilator testing.

Badesch DB, Tapson VF, McGoon MD, et al. Continuous intravenous epoprostenol for pulmonary hypertension due to scleroderma spectrum of disease. Ann Intern Med 2000; 132:425- 34. Noteworthy for showing benefit from prostacyclin in patients without idiopathic pulmonary arterial hypertension. RCT found prostacyclin improved exercise tolerance, modestly reduced PA pressures, and improved dyspnea scores in some patients, but was associated with frequent side effects and more adverse events. No difference in survival, but trial was only 12 weeks duration.

Blanco I, Gimeno E, Munoz P, et al. Hemodynamic and gas exchange effects of sildenafil in patients with chronic obstructive pulmonary disease and pulmonary hypertension. Am J Respir Crit Care Med. 2010;181:270-8The utility and safety of pulmonary artery vasodilators in patients with pulmonary hypertension and parenchymal lung disease remains uncertain despite this being a relatively common clinical problem. This small study of 20 patients with COPD and pulmonary hypertension demonstrated a single dose of sildenafil (20 or 40 mg) decreased mean PAP by 6 mmHg at rest and 11 mmHg with exercise, with a concomitant decrease in

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PaO2 of 6 mmHg at rest and 1 mmHg with exercise due to inhibition of hypoxic vasoconstriction. Suggests sildenafil may benefit pulmonary hemodynamics in this population, though also highlights the need for close monitoring of oxygenation and longer term assessment of efficacy.

SLEEP MEDICINE:

Iber C, O'Brien C, Schluter J, et al. Single night studies in obstructive sleep apnea. Sleep 1991;14:383-5. Contrary to the accompanying editorial, this study first documented the effectiveness of split-night studies for the evaluation of OSA and helped establish split-night studies as the standard of care.

Collop NA, Anderson WM, et al. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2007; 3:737-47.. The use of portable monitors is likely to increase in the U.S. now that it is reimbursed by Medicare. The task force recommends use of unattended portable monitoring studies be limited to patients with a high likelihood of moderate to severe OSA and at minimum record airflow, respiratory effort, and oxygen saturation. The evaluation should be supervised by a board-certified or eligible sleep physician.

Mulgrew AT, Fox N, Ayas NT, et al. Diagnosis and initial management of obstructive sleep apnea without polysomnography. Ann Intern Med 2007;146:157-166. Randomized validation study concluded that for patients with a high clinical probability of OSA (based on clinical features and overnight oximetry alone), PSG confers no advantage over ambulatory auto-titrating CPAP for the initial diagnosis and management of OSA.

Antic NA, Buchan C, Esterman A, et al. A randomized controlled trial of nurse-led care for symptomatic moderate-severe obstructive sleep apnea. Am J Respir Crit Care Med 2009; 179:501-8. Study of 195 patients with high likelihood of moderate to severe OSA based on clinical features and home oximetry alone had outcomes with ambulatory auto-titrating CPAP similar to those achieved with laboratory PSG. The study was novel in that management was supervised by nurses with a mean of 8.3 years of experience in sleep CPAP therapy rather than physicians. Sleep physicians were consulted 15% of the time in the nurse-led arm. PSG revealed periodic limb movement in 5.3% and central apnea index > 5/hr in 2.1% of patients.

Haentjens P, Van Meerhaeghe A, Moscariello A, et al. The impact of continuous positive airway pressure on blood pressure in patients with obstructive sleep apnea syndrome: evidence from a meta-analysis of placebo-controlled randomized trials. Arch Intern Med. 2007; 167:757-64. In this meta-analysis of data from 12 randomized controlled trials, the pooled estimate of the effect of the CPAP intervention on 24-hour mean arterial blood pressure was a net decrease of 1.69 mm Hg (95% confidence interval, -2.69 to -0.69), with greater treatment-related reductions among patients with a more severe OSA and a better adherence to CPAP therapy.

Bradley TD, Logan AG, Kimoff RJ, et al. Continuous positive airway pressure for central sleep apnea and heart failure. N Engl J Med 2005; 353:2025-33. The oft-cited, randomized CANPAP study of 258 patients found use of CPAP in patients with CHF and Cheyne-Stokes Respirations did not improve mortality. Some believe the lack of benefit compared to previous studies is due to advances in CHF treatment with beta blockers.

Mokhlesi B, Kryger MH, Grunstein RR. Assessment and management of patients with obesity hypoventilation syndrome. Proc Am Thorac Soc. 2008; 5:218-25. Reviews the clinical presentation, pathophysiology, morbidity, mortality, and currently available treatment of obesity hypoventilation syndrome.

Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med. 2004; 351:1838-48. Prospective, randomized study determined that interns made substantially more serious medical errors when they worked frequent shifts of 24 hours or more than when they worked shorter shifts. Eliminating extended work shifts and reducing the number of hours interns work per week can reduce serious medical errors in the intensive care unit.

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Earley, CJ. Restless legs syndrome. N Engl J Med 2003; 348:2103-9. The review offers a concise summary of the evaluation and management of RLS.

SMOKING CESSATION:

Fiore MC, Jaen CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. The following website offers the latest comprehensive AHRQ guidelines. The “Abstract” and “Executive Summary” links on the left margin provide succinct summaries that integrate the use of pharmacologic and non-pharmacologic approaches to smoking cessation.

Transdermal Nicotine Study Group. Transdermal nicotine for smoking cessation. Six-month results from two multicenter controlled clinical trials. JAMA 1991; 266:3133-8. This study assessed rates of continuous smoking abstinence among patients who had successfully quit after a 6-week trial of transdermal nicotine replacement. 26% of patients that had been randomized 21 mg patches were not smoking at 6 months compared to 12% in the placebo group.

Jorenby DE, Leischow SJ, Nides MA, et al. A controlled trial of sustained-release bupropion, a nicotine patch, or both for smoking cessation. N Engl J Med 1999; 340:685-91. This trial randomized nearly 900 patients to bupropion, a nicotine patch, bupropion plus a patch, or placebo. 12 month cessation rates were 30.3% for bupropion, 16.4% for the patch, 15.6% for placebo, and 35.5% with combined bupropion and patch. 12% of patients did not tolerate bupropion.

Gonzales D, Rennard SI, Nides M, et al. Varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation: a randomized, controlled trial. JAMA 2006; 296:47-55. This, along with another simultaneously published study by Jorenby DE et al in the same issue, randomized over 1000 patients to 12 weeks of varenicline (Chantix), bupropion, or placebo. Continuous abstinence for weeks 9 through 52 were 21.9% for varenicline, 16.1% for bupropion, and 8.4% for placebo (p = .057 for varenicline vs bupropion).

Anthonisen NR, Skeans MA, Wise RA, et al. The effects of a smoking cessation on 14.5 year mortality. Ann Intern Med 2005; 142:233-9. This article is noteworthy for showing smoking cessation reduces mortality even when the intervention is successful in only a minority of patients. The study compared a 10-week intervention that combined counseling and nicotine gum with usual care among smokers with obstructive lung disease. Quit rates at 5 years were 21.7% and 5.4% in the intervention and usual care groups, respectively. At 14.5 years, the hazard ratio for all-cause mortality in the usual care group vs. the intervention group was 1.18 (95% CI 1.02 to 1.37).